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Akiki K, Mahmoud T, Alqaisieh MH, Sayegh LN, Lescalleet KE, Abu Dayyeh BK, Wong Kee Song LM, Larson MV, Bruining DH, Coelho-Prabhu N, Buttar NS, Sedlack RE, Chandrasekhara V, Leggett CL, Law RJ, Rajan E, Gleeson FC, Alexander JA, Storm AC. A novel blood-sensing capsule for rapid detection of upper GI bleeding: a prospective clinical trial. Gastrointest Endosc 2024; 99:712-720. [PMID: 38065512 DOI: 10.1016/j.gie.2023.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/07/2023] [Accepted: 11/23/2023] [Indexed: 04/24/2024]
Abstract
BACKGROUND AND AIMS Upper GI bleeding (UGIB) is a common medical emergency associated with high resource utilization, morbidity, and mortality. Timely EGD can be challenging from personnel, resource, and access perspectives. PillSense (EnteraSense Ltd, Galway, Ireland) is a novel swallowed bleeding sensor for the detection of UGIB, anticipated to aid in patient triage and guide clinical decision-making for individuals with suspected UGIB. METHODS This prospective, open-label, single-arm comparative clinical trial of a novel bleeding sensor for patients with suspected UGIB was performed at a tertiary care center. The PillSense system consists of an optical sensor and an external receiver that processes and displays data from the capsule as "Blood Detected" or "No Blood Detected." Patients underwent EGD within 4 hours of capsule administration; participants were followed up for 21 days to confirm capsule passage. RESULTS A total of 126 patients were accrued to the study (59.5% male; mean age, 62.4 ± 14.3 years). Sensitivity and specificity for detecting the presence of blood were 92.9% (P = .02) and 90.6% (P < .001), respectively. The capsule's positive and negative predictive values were 74.3% and 97.8%, and positive and negative likelihood ratios were 9.9 and .08. No adverse events or deaths occurred related to the PillSense system, and all capsules were excreted from patients on follow-up. CONCLUSIONS The PillSense system is safe and effective for detecting the presence of blood in patients evaluated for UGIB before upper GI endoscopy. It is a rapidly deployed tool, with easy-to-interpret results that will affect the diagnosis and triage of patients with suspected UGIB. (Clinical trial registration number: NCT05385224.).
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Affiliation(s)
- Karl Akiki
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Mohammad H Alqaisieh
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Lea N Sayegh
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Kristin E Lescalleet
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mark V Larson
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | | | - Navtej S Buttar
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Robert E Sedlack
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan J Law
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology Mayo Clinic, Rochester, Minnesota, USA.
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Maalouf E, Khasawneh H, Karbhari A, AlAsfoor S, Breen-Lyles M, Bernard C, Rajan E, Farrugia G, Lowe V, Goenka A, Grover M. Preliminary study on the dynamic positron emission tomography imaging with 11C-ER176 to delineate macrophage activation in diabetic gastroparesis. Neurogastroenterol Motil 2024; 36:e14762. [PMID: 38376247 DOI: 10.1111/nmo.14762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Animal models and human data have suggested macrophage-driven immune dysregulation in diabetic gastroparesis (DG). Translocator protein (TSPO) upregulation has been suggested to indicate activated state of macrophages and ER176 is a high affinity third generation TSPO-specific radioligand. The aim of this study was to determine feasibility of dynamic 11C-ER 176 PET to identify macrophage activation in DG. METHODS Twelve patients, all females, were recruited (4 DG, 4 diabetics, and 4 healthy volunteers) for 11C-ER 176 PET/CT scanning. The standardized uptake value (SUVmax) in the gastric fundus, body, pylorus, and descending part of the duodenum were compared between three groups using Kruskal-Wallis test to perform the comparisons, and a p-value of 0.05 was considered statistically significant. KEY RESULTS Age was comparable among the three groups with a median of 53 years. The uptake was higher in pylorus in diabetics compared to DG and healthy (SUVmax healthy 4.6 ± 0.2, diabetics 8.4 ± 4.1, DG 5.5 ± 1.0, p = 0.04). The uptake was similar in gastric fundus (9.0 ± 1.6, 13.1 ± 8.3, 7.8 ± 1.9 respectively, p = 0.3), body (7.7 ± 1.9, 13 ± 9.2, 7.8 ± 1.9 respectively, p = 0.8), and duodenum (6.2 ± 2.1, 9.5 ± 6.8, 7.0 ± 1.8 respectively, p = 0.6). No correlation was observed between SUVmax uptake and either HbA1C or fasting blood glucose. CONCLUSIONS AND INFERENCES Female diabetic gastroparesis patients did not demonstrate increased TSPO ligand 11C-ER 176 uptake in the stomach. Possible explanations include lack of specificity of ligand for specific macrophage phenotypes in DG, sex effect, or small sample size. Further studies investigating non-invasive ways of analyzing immune dysregulation in neurogastrointestinal disorders are warranted.
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Affiliation(s)
- Elisia Maalouf
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hala Khasawneh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Aashna Karbhari
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shefaa AlAsfoor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Margaret Breen-Lyles
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cheryl Bernard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gianrico Farrugia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Val Lowe
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ajit Goenka
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Madhusudan Grover
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Salame M, Gleeson FC, Chandrasekhara V, Law RJ, Rajan E, Iyer PG, Bofill-Garcia A, Ghanem OM, Abu Dayyeh BK, Ravi A, Storm AC, Vargas EJ. SAFETY OF ENDOSCOPIC ULTRASONOGRAPHY LATEX BALLOON USE IN PATIENTS WITH A LATEX ALLERGY. Gastrointest Endosc 2024:S0016-5107(24)00051-8. [PMID: 38280533 DOI: 10.1016/j.gie.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND AND AIMS Balloons are used in endoscopic ultrasonography (EUS) to improve visualization. However, data on the safety of latex balloons in patients with latex allergies is limited, and non-latex alternatives can be costly. We aimed to investigate the safety of latex balloon use during EUS. METHODS A retrospective review was conducted at a tertiary center between 2019-2022. Patients with reported latex allergies who underwent linear EUS were included. Baseline demographics, EUS characteristics, and adverse events were collected. The primary outcome was the rate of adverse events. RESULTS 87 procedures were performed on 57 unique patients (mean age 65.3± 14.5 years). Latex balloons were used in 59 procedures (67.8%), with only 8 procedures (13.6%) using prophylactic medications. No adverse events occurred during or after procedures, regardless of medication use or history of anaphylaxis. CONCLUSIONS The use of EUS latex balloons in patients with a latex allergy was associated with no adverse events.
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Affiliation(s)
- Marita Salame
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Ryan J Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Anupama Ravi
- Division of Pediatric Allergy and Immunology, Mayo Clinic, Rochester, MN, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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AbiMansour J, Kamba S, Wong Kee Song LM, Rajan E. Through-the-scope clip retention rates and performance in a porcine model. Endosc Int Open 2024; 12:E52-E56. [PMID: 38193006 PMCID: PMC10774014 DOI: 10.1055/a-2221-7908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/17/2023] [Indexed: 01/10/2024] Open
Abstract
Background and study aims Limited comparative data exist to guide optimal through-the-scope (TTS) clip selection. The aim of this study was to compare the efficacy, retention, and safety of three industry-leading TTS clips on tissue that mimics common clinical scenarios. Methods A survival study involving six domestic pigs was undertaken. Three commonly used clip models were selected: Assurance (STERIS, Mentor, Ohio, United States), Resolution (Boston Scientific, Boston, Massachusetts, United States), and SureClip (Micro-Tech, Ann Arbor, Michigan, United States). To mimic clinical practice, the following scenarios were assessed: (1) normal mucosa; (2) cold snare resection; and (3) hot mucosal resection simulating fibrotic ulcers. Deployment of clips was randomized to target sites. Repeat endoscopy was performed 2 weeks following placement. Endoscopists rated the ease of use of clip placement on a Likert scale of 1 to 5. Results Fifty-four clips (18 Assurance, 18 Resolution, and 18 SureClip) were placed in six pigs. Mucosal healing was noted at all sites on follow up. Overall retention was nine of 18 (50.0%) SureClip, 10 of 18 (55.6%) Assurance, and 13 of 18 (72.2%) Resolution ( P =0.369). There was no difference in clip retention on normal and cold snare resection sites; however, clip retention was significantly higher for Resolution clips on fibrotic ulcers (50.0% versus 0% for Assurance and 0% SureClip, P =0.03). No adverse events were reported. Ease of use was equivalent across all models. Conclusions All clips were equivalent in efficacy and safety with successful clip deployment and mucosal healing. Overall retention rate was low for fibrotic tissue, with an improved retention rate observed with Resolution clips.
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Affiliation(s)
- Jad AbiMansour
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
| | - Shunsuke Kamba
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
| | | | - Elizabeth Rajan
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, United States
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AbiMansour JP, Rajan E. Improving suboptimal bowel prep using a novel on-demand overtube device: an in vivo animal study. VideoGIE 2023; 8:127-129. [PMID: 36935815 PMCID: PMC10019980 DOI: 10.1016/j.vgie.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Video 1Use of a novel, on-demand overtube to perform a targeted right colonic enema and improve suboptimal bowel preparation.
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Affiliation(s)
- Jad P AbiMansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
- Developmental Endoscopy Unit, Mayo Clinic, Rochester, Minnesota
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Hernandez A, Marya NB, Sawas T, Rajan E, Gades NM, Wong Kee Song LM, Abu Dayyeh BK, Buttar N, Storm AC. Erratum: Gastrointestinal defect closure using a novel through-the-scope helix tack and suture device compared to endoscopic clips in a survival porcine model (with video). Endosc Int Open 2022; 9:C12. [PMID: 35527742 PMCID: PMC9068276 DOI: 10.1055/a-1834-5697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
[This corrects the article DOI: 10.1055/a-1370-9256.].
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Affiliation(s)
- Ariosto Hernandez
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Mayo Clinic Developmental Endoscopy Unit, Rochester, Minnesota, United States
| | - Neil B. Marya
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Tarek Sawas
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Elizabeth Rajan
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Mayo Clinic Developmental Endoscopy Unit, Rochester, Minnesota, United States
| | - Naomi M. Gades
- Department of Comparative Medicine, Mayo Clinic, Scottsdale, Arizona, United States
| | - Louis M. Wong Kee Song
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Navtej Buttar
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Andrew C. Storm
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Mayo Clinic Developmental Endoscopy Unit, Rochester, Minnesota, United States
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Hernandez-Lara A, Abu Dayyeh BK, Garcia de Paredes A, Rajan E, Storm AC. Endoscopically directed single-port intragastric fundoplication, sleeve gastroplasty, and myotomy: a preclinical study in a porcine model. VideoGIE 2022; 7:102-105. [PMID: 35287367 PMCID: PMC8917358 DOI: 10.1016/j.vgie.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Garcia Garcia de Paredes A, Graham RP, Levy MJ, McWilliams RR, Rajan E, Zhang L, Gleeson FC. Utility of mismatch repair protein expression screening via an endoscopic ultrasound assessment of treatment-naive pancreas ductal adenocarcinoma. Gut 2022; 71:219-221. [PMID: 33731370 DOI: 10.1136/gutjnl-2021-324460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Garcia Garcia de Paredes
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,Gastroenterology and Hepatology Department, Hospital Universitario Ramon y Cajal, Universidad de Alcala. IRYCIS, Madrid, Spain
| | - Rondell P Graham
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lizhi Zhang
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Kamani L, Butt N, Taufiq F, de Paredes AG, Rajan E. Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey. Gastrointest Endosc 2021; 94:1110-1115. [PMID: 34228980 DOI: 10.1016/j.gie.2021.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/22/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Patient preference for a healthcare professional is mediated by physician gender. The primary aim of this study was to assess gender preference for an endoscopist in a cohort of Muslim patients. The secondary aim was to identify factors that influence gender preference. METHODS This was a multicenter cross-sectional study conducted at 3 tertiary care hospitals in Pakistan. Consecutive patients scheduled for elective outpatient upper endoscopy or colonoscopy were asked to complete a questionnaire immediately before and after the procedure. Data collected included patient demographics, occupation, education level, procedure type, gender preference, and reason for preference. RESULTS A total of 1078 patients completed the questionnaire (age 43.5 ± 15.8 years; 53.2% men). Upper endoscopy was the most frequent procedure, performed in 84% of patients. Gender preference was expressed by 707 patients (65.6%), of which 511 (72.3%) were willing to wait for an average of 7 days for an endoscopist of the preferred gender. Male patients' preferences (45.1% male endoscopist, 17.1% female endoscopist, 37.8% no preference) differed from female participants' (16.9% male endoscopist, 52.6% female endoscopist, and 30.5% no preference; P < .00001). No education was associated with having a gender preference (odds ratio, .55; 95% confidence interval, .37-.81; P = .003). Reasons for gender preference included religious values and family pressure, which were more frequently expressed by women (P < .0001). CONCLUSIONS Most Muslims in Pakistan expressed a gender preference, and both female and male patients showed a preference for a same-gender endoscopist. No education was associated with having a gender preference.
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Affiliation(s)
- Lubna Kamani
- Gastroenterology Department, Liaquat National Hospital, Karachi, Pakistan
| | - Nazish Butt
- Gastroenterology Department, Jinnah Post Graduate Medical Centre, Karachi, Pakistan
| | - Farheen Taufiq
- Gastroenterology Department, Liaquat National Hospital, Karachi, Pakistan
| | - Ana Garcia de Paredes
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Cash BD, Fleisher MR, Fern S, Rajan E, Haithcock R, Kastenberg DM, Pound D, Papageorgiou NP, Fernández-Urién I, Schmelkin IJ, Rex DK. Multicentre, prospective, randomised study comparing the diagnostic yield of colon capsule endoscopy versus CT colonography in a screening population (the TOPAZ study). Gut 2021; 70:2115-2122. [PMID: 33443017 DOI: 10.1136/gutjnl-2020-322578] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Colon capsule endoscopy (CCE) has shown promise for colorectal neoplasia detection compared with optical colonoscopy (OC), but has not been compared with other screening tests in average risk screening patients. DESIGN Patients 50 to 75 years of age (African Americans, 45-75 years) were randomised to CCE or CT colonography (CTC) and subsequent blinded OC. The primary endpoint was diagnostic yield of polyps ≥6 mm with CCE or CTC. Secondary endpoints included accuracy for size and histology, examination completeness, number/proportion of subjects with polyps and adenomas ≥6 mm and ≥10 mm, subject satisfaction and safety. RESULTS From 320 enrolled subjects, data from 286 (89.4%) were evaluable. The proportion of subjects with any polyp ≥6 mm confirmed by OC was 31.6% for CCE versus 8.6% for CTC (pPr non-inferiority and superiority=0.999). The diagnostic yield of polyps ≥10 mm was 13.5% with CCE versus 6.3% with CTC (pPr non-inferiority=0.9954). The sensitivity and specificity of CCE for polyps ≥6 mm was 79.2% and 96.3% while that of CTC was 26.8% and 98.9%. The sensitivity and specificity of CCE for polyps ≥10 mm was 85.7% and 98.2% compared with 50% and 99.1% for CTC. Both tests were well tolerated/safe. CONCLUSION CCE was superior to CTC for detection of polyps ≥6 mm and non-inferior for identification of polyps ≥10 mm. CCE should be considered comparable or superior to CTC as a colorectal neoplasia screening test, although neither test is as effective as OC. TRIAL REGISTRATION NUMBER ClinicalTrials.gov no: NCT02754661.
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Affiliation(s)
- Brooks D Cash
- Gastroenterology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mark R Fleisher
- Gastroenterology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Steven Fern
- Specialists in Gastroenterology, Clinical Research Professionals, Saint Louis, Missouri, USA
| | - Elizabeth Rajan
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robyn Haithcock
- MultiCare Medical Division Gastroenterology, Clinical Research Professionals, Chesterfield, Missouri, USA
| | - David M Kastenberg
- Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Pound
- Indianapolis Gastroenterology and Hepatology, Indianapolis, Indiana, USA
| | | | - Ignacio Fernández-Urién
- Department of Gastroenterology and Hepatology, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | - Ira J Schmelkin
- Gastroenterology, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Douglas K Rex
- Indiana University School of Medicine, Indiana University Hospital, Indianapolis, Indiana, USA
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Marya NB, Powers PD, Chari ST, Gleeson FC, Leggett CL, Abu Dayyeh BK, Chandrasekhara V, Iyer PG, Majumder S, Pearson RK, Petersen BT, Rajan E, Sawas T, Storm AC, Vege SS, Chen S, Long Z, Hough DM, Mara K, Levy MJ. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut 2021; 70:1335-1344. [PMID: 33028668 DOI: 10.1136/gutjnl-2020-322821] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The diagnosis of autoimmune pancreatitis (AIP) is challenging. Sonographic and cross-sectional imaging findings of AIP closely mimic pancreatic ductal adenocarcinoma (PDAC) and techniques for tissue sampling of AIP are suboptimal. These limitations often result in delayed or failed diagnosis, which negatively impact patient management and outcomes. This study aimed to create an endoscopic ultrasound (EUS)-based convolutional neural network (CNN) model trained to differentiate AIP from PDAC, chronic pancreatitis (CP) and normal pancreas (NP), with sufficient performance to analyse EUS video in real time. DESIGN A database of still image and video data obtained from EUS examinations of cases of AIP, PDAC, CP and NP was used to develop a CNN. Occlusion heatmap analysis was used to identify sonographic features the CNN valued when differentiating AIP from PDAC. RESULTS From 583 patients (146 AIP, 292 PDAC, 72 CP and 73 NP), a total of 1 174 461 unique EUS images were extracted. For video data, the CNN processed 955 EUS frames per second and was: 99% sensitive, 98% specific for distinguishing AIP from NP; 94% sensitive, 71% specific for distinguishing AIP from CP; 90% sensitive, 93% specific for distinguishing AIP from PDAC; and 90% sensitive, 85% specific for distinguishing AIP from all studied conditions (ie, PDAC, CP and NP). CONCLUSION The developed EUS-CNN model accurately differentiated AIP from PDAC and benign pancreatic conditions, thereby offering the capability of earlier and more accurate diagnosis. Use of this model offers the potential for more timely and appropriate patient care and improved outcome.
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Affiliation(s)
- Neil B Marya
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Suresh T Chari
- Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ferga C Gleeson
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Prasad G Iyer
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shounak Majumder
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall K Pearson
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tarek Sawas
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shigao Chen
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zaiyang Long
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Hough
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin Mara
- Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael J Levy
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Hernandez-Lara A, Garcia Garcia de Paredes A, Rajan E, Storm AC. Step-by-step instruction: using an endoscopic tack and suture device for gastrointestinal defect closure. VideoGIE 2021; 6:243-245. [PMID: 34141961 PMCID: PMC8187141 DOI: 10.1016/j.vgie.2021.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
| | | | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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13
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Garcia Garcia de Paredes A, Gleeson FC, Rajan E, Vazquez-Sequeiros E. Current clinical and research fluid biomarkers to aid risk stratification of pancreatic cystic lesions. Rev Esp Enferm Dig 2021; 113:714-720. [PMID: 33947199 DOI: 10.17235/reed.2021.7948/2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pancreatic cystic lesions (PCL) are composed of a heterogeneous group of entities that are increasingly diagnosed, generally as incidental findings in asymptomatic patients. In conjunction with this growing incidence, the potential for malignant transformation of mucin-producing cysts makes PCL a challenging clinical conundrum for the clinician, patient, and healthcare system. Cyst characterization based on morphology is often difficult and inaccurate, therefore several intracystic fluid biomarkers have been evaluated as ancillary testing to enhance the difficult balance between sparing a patient from an unnecessary high-risk pancreatic surgery and missing the opportunity to prevent or diagnose pancreatic adenocarcinoma at an early disease stage. There are two questions that are key to guide the care of patients with PCL: 1) is it a non-mucinous cyst that does not require any follow-up? and 2) if mucinous, does the cyst harbor advanced neoplasia (high-grade dysplasia or invasive carcinoma) that requires surgical resection, or is it a low-risk lesion that will benefit from a surveillance program? The purpose of this review is to give a general and practical overview of the different cyst fluid biomarkers that have been studied to address these specific questions, from classic biochemical markers to include carcinoembryonic antigen to novel genetic and epigenetic markers, such as microRNA or intracystic bacterial DNA.
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Marya NB, Powers PD, Fujii-Lau L, Abu Dayyeh BK, Gleeson FC, Chen S, Long Z, Hough DM, Chandrasekhara V, Iyer PG, Rajan E, Sanchez W, Sawas T, Storm AC, Wang KK, Levy MJ. Application of artificial intelligence using a novel EUS-based convolutional neural network model to identify and distinguish benign and malignant hepatic masses. Gastrointest Endosc 2021; 93:1121-1130.e1. [PMID: 32861752 DOI: 10.1016/j.gie.2020.08.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Detection and characterization of focal liver lesions (FLLs) is key for optimizing treatment for patients who may have a primary hepatic cancer or metastatic disease to the liver. This is the first study to develop an EUS-based convolutional neural network (CNN) model for the purpose of identifying and classifying FLLs. METHODS A prospective EUS database comprising cases of FLLs visualized and sampled via EUS was reviewed. Relevant still images and videos of liver parenchyma and FLLs were extracted. Patient data were then randomly distributed for the purpose of CNN model training and testing. Once a final model was created, occlusion heatmap analysis was performed to assess the ability of the EUS-CNN model to autonomously identify FLLs. The performance of the EUS-CNN for differentiating benign and malignant FLLs was also analyzed. RESULTS A total of 210,685 unique EUS images from 256 patients were used to train, validate, and test the CNN model. Occlusion heatmap analyses demonstrated that the EUS-CNN model was successful in autonomously locating FLLs in 92.0% of EUS video assets. When evaluating any random still image extracted from videos or physician-captured images, the CNN model was 90% sensitive and 71% specific (area under the receiver operating characteristic [AUROC], 0.861) for classifying malignant FLLs. When evaluating full-length video assets, the EUS-CNN model was 100% sensitive and 80% specific (AUROC, 0.904) for classifying malignant FLLs. CONCLUSIONS This study demonstrated the capability of an EUS-CNN model to autonomously identify FLLs and to accurately classify them as either malignant or benign lesions.
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Affiliation(s)
- Neil B Marya
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Larissa Fujii-Lau
- Department of Gastroenterology, The Queen's Medical Center, Honolulu, Hawaii
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Shigao Chen
- Division of Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zaiyang Long
- Division of Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Hough
- Division of Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - William Sanchez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Tarek Sawas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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15
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Hernandez A, Marya NB, Sawas T, Rajan E, Gades NM, Wong Kee Song LM, Abu Dayyeh BK, Buttar N, Storm AC. Gastrointestinal defect closure using a novel through-the-scope helix tack and suture device compared to endoscopic clips in a survival porcine model (with video). Endosc Int Open 2021; 9:E572-E577. [PMID: 33860074 PMCID: PMC8041572 DOI: 10.1055/a-1370-9256] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/23/2020] [Indexed: 12/18/2022] Open
Abstract
Background and aims Endoscopic resections are associated with bleeding and perforation and may be managed with through-the-scope (TTS) clips, over-the-scope clips and endoscopic suturing. The aim of this preclinical study was to compare technical success of closure using a novel TTS tissue helix tack and suture device (X-Tack) to TTS clips in a porcine model. Materials and methods Four subjects underwent 40 mucosal resections, diameter range 25-50 mm, in the stomach (n = 24) and colon (n = 16). Closures were randomized to X-Tack (n = 24) or clip (n = 16). Animals underwent weekly endoscopic follow-up for 4 weeks. Results Technical closure with X-Tack was successful in 24 of 24 (100 %) cases and with clips in 13 of 16 cases (81.3 %) ( P = 0.0001). One colonic perforation occurred and was successfully managed using X-Tack. The rate of healing was not statistically different between the groups, and all sites healed at 4 weeks including the perforation and were confirmed by histology. Conclusions Compared to TTS clip, X-Tack is superior for effecting large mucosal defect closure, including durable sealing of full-thickness perforation. There was no difference in rate of healing between devices.
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Affiliation(s)
- Ariosto Hernandez
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Mayo Clinic Developmental Endoscopy Unit, Rochester, Minnesota, United States
| | - Neil B. Marya
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Tarek Sawas
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Elizabeth Rajan
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Mayo Clinic Developmental Endoscopy Unit, Rochester, Minnesota, United States
| | - Naomi M. Gades
- Department of Comparative Medicine, Mayo Clinic, Scottsdale, Arizona, United States
| | - Louis M. Wong Kee Song
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Navtej Buttar
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Andrew C. Storm
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Mayo Clinic Developmental Endoscopy Unit, Rochester, Minnesota, United States
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16
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Hernandez-Lara AH, de Paredes AGG, Song LMWK, Rowan DJ, Graham RP, Levy MJ, Gleeson FC, Kamboj AK, Mara KC, Abu-Dayyeh BK, Chandrasekhara V, Iyer PG, Storm AC, Rajan E. Outcomes of endoscopic ultrasound and endoscopic resection of gastrointestinal subepithelial lesions: a single-center retrospective cohort study. Ann Gastroenterol 2021; 34:516-520. [PMID: 34276190 PMCID: PMC8276353 DOI: 10.20524/aog.2021.0621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/03/2021] [Indexed: 11/11/2022] Open
Abstract
Background Endoscopic resection (ER) is an emerging therapeutic alternative for subepithelial gastrointestinal lesions (SELs). We aimed to determine whether size, layer of origin, and histology based on endoscopic ultrasound (EUS) and EUS-guided sampling (EUS-GS) influenced the outcomes and selection of patients for ER. Methods We performed a retrospective review of patients who underwent EUS, EUS-GS and resection of SELs from 2012-2019. Two pathologists reviewed the histology and layer of origin of all resected specimens, serving as the criterion for EUS accuracy. Results Seventy-three patients were included, of whom 59 (81%) were gastric SELs. Per EUS, median lesion size was 21 mm (interquartile range 15-32), and 63 (86%) originated from the 4th layer. The overall accuracy of EUS and EUS-GS in predicting the layer of origin and histology was 88% (95% confidence interval [CI] 77-94%) and 96% (95%CI 87-98%), respectively. Based on EUS, 18 (25%) patients were referred for ER, 5 (7%) to laparoscopic-endoscopic cooperative surgery, and 50 (68%) to surgery. Size >20 mm was associated with the type of resection approach (P=0.005), while layer of origin and histology were not (P=0.06 and P=0.09, respectively). When SELs were inaccurately classified (n=4) there were no adverse events or revision of the resection approach. Conclusions EUS plays an important role in the outcome of resection approach for SELs, with size significantly influencing the selection for ER. In patients undergoing ER, no revised resections were needed when EUS was inaccurate.
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Affiliation(s)
- Ariosto H Hernandez-Lara
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Ana Garcia Garcia de Paredes
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Daniel J Rowan
- Department of Anatomic Pathology (Daniel J. Rowan, Rondell P. Graham)
| | - Rondell P Graham
- Department of Anatomic Pathology (Daniel J. Rowan, Rondell P. Graham)
| | - Michael J Levy
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Amrit K Kamboj
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Kristin C Mara
- Department of Biomedical Statistics and Informatics (Kristin C. Mara), Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu-Dayyeh
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology (Ariosto H. Hernandez-Lara, Ana Garcia Garcia de Paredes, Louis M. Wong Kee Song, Michael J. Levy, Ferga C. Gleeson, Amrit K. Kamboj, Barham K. Abu-Dayyeh, Vinay Chandrasekhara, Prasad G. Iyer, Andrew C. Storm, Elizabeth Rajan)
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17
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Malikowski T, Levy MJ, Gleeson FC, Storm AC, Vargas EJ, Topazian MD, Abu Dayyeh BK, Iyer PG, Rajan E, Gores GJ, Roberts LR, Chandrasekhara V. Endoscopic Ultrasound/Fine Needle Aspiration Is Effective for Lymph Node Staging in Patients With Cholangiocarcinoma. Hepatology 2020; 72:940-948. [PMID: 31860935 DOI: 10.1002/hep.31077] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 12/09/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Presence of malignant regional lymph nodes (MRLNs) precludes curative oncological resection or liver transplantation for cholangiocarcinoma (CCA). Limited data support the utility of endoscopic ultrasound (EUS)/fine needle aspiration (FNA) for detection of MRLNs in extrahepatic CCA, but there are no data for its role in intrahepatic CCA (iCCA). The aim of this study is to evaluate the staging impact of EUS for CCA, including analysis by subtype. APPROACH AND RESULTS We identified consecutive patients with CCA who underwent EUS staging at a single tertiary care center from October 2014 to April 2018. Among this cohort, we abstracted clinical demographic, radiographical, procedural, cytopathological, and surgical data. STATA 15 software was used for comparative analysis calculations (StataCorp LP, College Station, TX). The study cohort included 157 patients; 24 (15%), 124 (79%), and 9 (6%) with intrahepatic, perihilar, and distal CCA, respectively. EUS was able to identify regional lymph nodes (RLNs) in a higher percentage of patients compared to cross-sectional imaging (86% vs. 47%; P < 0.001). FNA was performed in 133 (98.5%) patients with RLNs, with a median of three passes per node. EUS-FNA identified MRLN in 27 of 31 (87.1%) patients ultimately found to have MRLNs. For iCCA, EUS detected a higher percentage of RLN compared to cross-sectional imaging (83% vs. 50%; P = 0.048), with MRLNs identified in 4 (17%) patients. Among the entire cohort, identification of at least one MRLN by EUS was associated with lower median survival (353 vs. 1,050 days; P < 0.001) and increased risk of death (hazard ratio = 4.1; P < 0.001). CONCLUSIONS EUS-FNA is effective for identifying MRLN in patients with CCA, and should be routinely incorporated into staging of all CCA subtypes given the impact of MRLN on prognosis and management decisions.
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Affiliation(s)
- Thomas Malikowski
- Department of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | - Andrew C Storm
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | - Eric J Vargas
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
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18
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Rajan E, Martinez M, Gorospe E, Al Bawardy B, Dobashi A, Mara KC, Hansel SL, Bruining DH, Murray JA, Leggett CL, Nehra V, Iyer PG, Pasha SF, Leighton JA, Shiff AD, Gurudu SR, Raffals LE, Lavey C, Katzka DA, Chen CHH. Prospective multicenter study to evaluate capsule endoscopy competency using a validated assessment tool. Gastrointest Endosc 2020; 91:1140-1145. [PMID: 31883863 DOI: 10.1016/j.gie.2019.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/10/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Capsule endoscopy (CE) is an established, noninvasive modality for examining the small bowel. Minimum training requirements are based primarily on guidelines and expert opinion. A validated tool to assess the competence of CE is lacking. In this prospective, multicenter study, we determined the minimum number of CE procedures required to achieve competence during gastroenterology fellowship; validated a capsule competency test (CapCT); and evaluated any correlation between CE competence and endoscopy experience. METHODS We included second- and third-year gastroenterology fellows from 3 institutions between 2013 and 2018 in a structured CE training program with supervised CE interpretation. Fellows completed the CapCT with a maximal score of 100. For comparison, expert faculty completed the same CapCT. Trainee competence was defined as a score ≥90% compared with the mean expert score. Fellows were tested after 15, 25, and 35 supervised CE interpretations. CapCT was validated using expert consensus and item analysis. Data were collected on the number of previous endoscopies. RESULTS A total of 68 trainees completed 102 CapCTs. Fourteen CE experts completed the CapCT with a mean score of 94. Mean scores for fellows after 15, 25, and 35 cases were 83, 86, and 87, respectively. Fellows with at least 25 interpretations achieved a mean score ≥84 in all 3 institutions. CapCT item analysis showed high interobserver agreement among expert faculty (k = 0.85). There was no correlation between the scores and the number of endoscopies performed. CONCLUSION After a structured CE training program, gastroenterology fellows should complete a minimum of 25 supervised CE interpretations before assessing competence using the validated CapCT, regardless of endoscopy experience.
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Affiliation(s)
- Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manuel Martinez
- Division of Gastroenterology, New York Harbor VA, SUNY Downstate Medical Center, New York, New York, USA
| | - Emmanuel Gorospe
- Division of Gastroenterology, Hospitals of Providence Healthcare System, El Paso, Texas, USA
| | - Badr Al Bawardy
- Yale School of Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
| | - Akira Dobashi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephanie L Hansel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vandana Nehra
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shabana F Pasha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jonathan A Leighton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Arthur D Shiff
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Suryakanth R Gurudu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Crystal Lavey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Chien-Huan H Chen
- Division of Gastroenterology, Washington University, St. Louis, Missouri, USA
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Albitar HAH, Almodallal Y, Papadakis KA, Rajan E, Kamath PS, Iyer VN. Intravenous Bevacizumab Reduces Transfusion Requirements and Endoscopic Interventions in Patients With Gastric Antral Vascular Ectasia and Small Bowel Angioectasia. Gastroenterology 2020; 158:1162-1163.e4. [PMID: 31759060 DOI: 10.1053/j.gastro.2019.11.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/08/2019] [Accepted: 11/13/2019] [Indexed: 12/02/2022]
Affiliation(s)
| | | | | | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
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20
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Majumder S, Raimondo M, Taylor WR, Yab TC, Berger CK, Dukek BA, Cao X, Foote PH, Wu CW, Devens ME, Mahoney DW, Smyrk TC, Pannala R, Chari ST, Vege SS, Topazian MD, Petersen BT, Levy MJ, Rajan E, Gleeson FC, Dayyeh BA, Nguyen CC, Faigel DO, Woodward TA, Wallace MB, Petersen G, Allawi HT, Lidgard GP, Kisiel JB, Ahlquist DA. Methylated DNA in Pancreatic Juice Distinguishes Patients With Pancreatic Cancer From Controls. Clin Gastroenterol Hepatol 2020; 18:676-683.e3. [PMID: 31323382 PMCID: PMC6984349 DOI: 10.1016/j.cgh.2019.07.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 07/10/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Precursors of pancreatic cancer arise in the ductal epithelium; markers exfoliated into pancreatic juice might be used to detect high-grade dysplasia (HGD) and cancer. Specific methylated DNA sequences in pancreatic tissue have been associated with adenocarcinoma. We analyzed these methylated DNA markers (MDMs) in pancreatic juice samples from patients with pancreatic ductal adenocarcinomas (PDACs) or intraductal papillary mucinous neoplasms (IPMNs) with HGD (cases), and assessed their ability to discriminate these patients from individuals without dysplasia or with IPMNs with low-grade dysplasia (controls). METHODS We obtained pancreatic juice samples from 38 patients (35 with biopsy-proven PDAC or pancreatic cystic lesions with invasive cancer and 3 with HGD) and 73 controls (32 with normal pancreas and 41 with benign disease), collected endoscopically from the duodenum after secretin administration from February 2015 through November 2016 at 3 medical centers. Samples were analyzed for the presence of 14 MDMs (in the genes NDRG4, BMP3, TBX15, C13orf18, PRKCB, CLEC11A, CD1D, ELMO1, IGF2BP1, RYR2, ADCY1, FER1L4, EMX1, and LRRC4), by quantitative allele-specific real-time target and signal amplification. We performed area under the receiver operating characteristic curve analyses to determine the ability of each marker, and panels of markers, to distinguish patients with HGD and cancer from controls. MDMs were combined to form a panel for detection using recursive partition trees. RESULTS We identified a group of 3 MDMs (at C13orf18, FER1L4, and BMP3) in pancreatic juice that distinguished cases from controls with an area under the receiver operating characteristic value of 0.90 (95% CI, 0.83-0.97). Using a specificity cut-off value of 86%, this group of MDMs distinguished patients with any stage of pancreatic cancer from controls with 83% sensitivity (95% CI, 66%-93%) and identified patients with stage I or II PDAC or IPMN with HGD with 80% sensitivity (95% CI, 56%-95%). CONCLUSIONS We identified a group of 3 MDMs in pancreatic juice that identify patients with pancreatic cancer with an area under the receiver operating characteristic value of 0.90, including patients with early stage disease or advanced precancer. These DNA methylation patterns might be included in algorithms for early detection of pancreatic cancer, especially in high-risk cohorts. Further optimization and clinical studies are needed.
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Affiliation(s)
- Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Massimo Raimondo
- Division of Gastroenterology & Hepatology Mayo Clinic Jacksonville, FL
| | - William R. Taylor
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Tracy C. Yab
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Calise K. Berger
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Brian A. Dukek
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Xiaoming Cao
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Patrick H. Foote
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Chung Wah Wu
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Mary E. Devens
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Douglas W. Mahoney
- Department of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN
| | - Thomas C. Smyrk
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | - Rahul Pannala
- Division of Gastroenterology & Hepatology, Mayo Clinic Scottsdale, AZ
| | - Suresh T. Chari
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | | | - Mark D. Topazian
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Bret T. Petersen
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Michael J. Levy
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Elizabeth Rajan
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Ferga C. Gleeson
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Barham Abu Dayyeh
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Cuong C. Nguyen
- Division of Gastroenterology & Hepatology, Mayo Clinic Scottsdale, AZ
| | - Douglas O. Faigel
- Division of Gastroenterology & Hepatology, Mayo Clinic Scottsdale, AZ
| | | | | | - Gloria Petersen
- Department of Health Sciences Research Mayo Clinic, Rochester, MN
| | | | | | - John B. Kisiel
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - David A. Ahlquist
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
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21
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Malikowski T, Lehrke HD, Henry MR, Gleeson FC, Alberts SR, Kendrick ML, Lennon RJ, McWilliams RR, Takahashi N, Topazian MD, Gara N, Abu Dayyeh BK, Chandrasekhara V, Chari ST, Iyer PG, Rajan E, Storm AC, Wang KK, Levy MJ. Clinical impact of celiac ganglia metastasis upon pancreatic ductal adenocarcinoma. Pancreatology 2020; 20:110-115. [PMID: 31759906 DOI: 10.1016/j.pan.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/24/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pre-operative staging of pancreatic adenocarcinoma guides clinical decision making. Limited data indicate that metastasis to celiac ganglia (CG) correlates with poor prognosis. We investigated feasibility and safety of endoscopic ultrasound fine needle aspiration (EUS-FNA) detection of CG metastasis and its impact upon tumor stage, resectability, and survival in pancreatic ductal adenocarcinoma (PDAC). PATIENTS We reviewed our prospectively maintained EUS and cytopathology databases to identify patients with FNA proven CG metastasis in patients with PDAC from 2004 to 2017. Clinical demographics, EUS, CT, MRI, cytopathology, cancer stage, and resectability data were analyzed. Survival of PDAC patients with CG metastasis was compared to the expected survival of PDAC patients of similar stage as reported by the United States National Cancer Database. RESULTS Twenty-one patients with PDAC [median age 73 (IQR63-78); 14 (67%) female)], had CG metastasis confirmed by cytopathologic assessment. CG metastasis resulted in tumor upstaging relative to other EUS findings and cross sectional imaging findings in 12 (57%) and 15 (71%) patients, and converted cancers from resectable to unresectable relative to EUS and cross sectional imaging in 7 (37%) and 7 (37%) patients, respectively. In patients with PDAC, the survival of patients with CG metastasis was not significantly different from the overall survival (hazard ratio 0.71; 95% confidence interval 0.44, 1.13; p = 0.15). CONCLUSIONS EUS-FNA may safely identify CG metastases. While CG metastasis upstaged and altered the resectability status among this cohort of patients with PDAC, the survival data with regard to PDAC suggest that this may be misguided.
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Affiliation(s)
- Thomas Malikowski
- Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Heidi D Lehrke
- Division of Anatomic Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael R Henry
- Division of Anatomic Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Steven R Alberts
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert R McWilliams
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Naveen Gara
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrew C Storm
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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22
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Hansel SL, Murray JA, Alexander JA, Bruining DH, Larson MV, Mangan TF, Dierkhising RA, Almazar AE, Rajan E. Evaluating a combined bowel preparation for small-bowel capsule endoscopy: a prospective randomized-controlled study. Gastroenterol Rep (Oxf) 2019; 8:31-35. [PMID: 32419949 PMCID: PMC7217271 DOI: 10.1093/gastro/goz054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/15/2019] [Accepted: 08/23/2019] [Indexed: 12/15/2022] Open
Abstract
Background Capsule endoscopy (CE) is frequently hindered by intra-luminal debris. Our aim was to determine whether a combination bowel preparation would improve small-bowel visualization, diagnostic yield, and the completion rate of CE. Methods Single-blind, prospective randomized–controlled study of outpatients scheduled for CE. Bowel-preparation subjects ingested 2 L of polyethylene glycol solution the night prior to CE, 5 mL simethicone and 5 mg metoclopramide 20 minutes prior to CE and laid in the right lateral position 30 minutes after swallowing CE. Controls had no solid food after 7 p.m. the night prior to CE and no liquids 4 hours prior to CE. Participants completed a satisfaction survey. Capsule readers completed a small-bowel-visualization assessment. Results Fifty patients were prospectively enrolled (56% female) with a median age of 54.4 years and 44 completed the study (23 patients in the control group and 21 in the preparation group). There was no significant difference between groups on quartile-based small-bowel visualization (all P > 0.05). There was no significant difference between groups in diagnostic yield (P = 0.69), mean gastric (P = 0.10) or small-bowel transit time (P = 0.89). The small-bowel completion rate was significantly higher in the preparation group (100% vs 78%; P = 0.02). Bowel-preparation subjects reported significantly more discomfort than controls (62% vs 17%; P = 0.01). Conclusions Combined bowel preparation did not improve small-bowel visualization but did significantly increase patient discomfort. The CE completion rate improved in the preparation group but the diagnostic yield was unaffected. Based on our findings, a bowel preparation prior to CE does not appear to improve CE performance and results in decreased patient satisfaction (ClinicalTrials.gov, No. NCT01243736).
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Affiliation(s)
- Stephanie L Hansel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Mark V Larson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Thomas F Mangan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Ann E Almazar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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23
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Sinicrope FA, Velamala PR, Song LMWK, Viggiano TR, Bruining DH, Rajan E, Gostout CJ, Kraichely RE, Buttar NS, Schroeder KW, Kisiel JB, Larson MV, Sweetser SR, Sedlack RR, Sinicrope SN, Richmond E, Umar A, Della'Zanna G, Noaeill JS, Meyers JP, Foster NR. Efficacy of Difluoromethylornithine and Aspirin for Treatment of Adenomas and Aberrant Crypt Foci in Patients with Prior Advanced Colorectal Neoplasms. Cancer Prev Res (Phila) 2019; 12:821-830. [PMID: 31484660 DOI: 10.1158/1940-6207.capr-19-0167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/27/2019] [Accepted: 08/27/2019] [Indexed: 11/16/2022]
Abstract
Difluoromethylornithine (DFMO), an inhibitor of polyamine synthesis, was shown to act synergistically with a NSAID for chemoprevention of colorectal neoplasia. We determined the efficacy and safety of DFMO plus aspirin for prevention of colorectal adenomas and regression of rectal aberrant crypt foci (ACF) in patients with prior advanced adenomas or cancer. A double-blinded, placebo-controlled trial was performed in 104 subjects (age 46-83) randomized (1:1) to receive daily DFMO (500 mg orally) plus aspirin (325 mg) or matched placebos for one year. All polyps were removed at baseline. Adenoma number (primary endpoint) and rectal ACF (index cluster and total) were evaluated at a one year colonoscopy. ACF were identified by chromoendoscopy. Toxicity was monitored, including audiometry. Eighty-seven subjects were evaluable for adenomas or ACF modulation (n = 62). At one year of treatment, adenomas were detected in 16 (38.1%) subjects in the DFMO plus aspirin arm (n = 42) versus 18 (40.9%) in the placebo arm (n = 44; P = 0.790); advanced adenomas were similar (n = 3/arm). DFMO plus aspirin was associated with a statistically significant reduction in the median number of rectal ACF compared with placebo (P = 0.036). Total rectal ACF burden was also reduced in the treatment versus the placebo arm relative to baseline (74% vs. 45%, P = 0.020). No increase in adverse events, including ototoxicity, was observed in the treatment versus placebo arms. While adenoma recurrence was not significantly reduced by one year of DFMO plus aspirin, the drug combination significantly reduced rectal ACF number consistent with a chemopreventive effect.
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Affiliation(s)
- Frank A Sinicrope
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Pruthvi R Velamala
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Thomas R Viggiano
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David H Bruining
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Robert E Kraichely
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Navtej S Buttar
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth W Schroeder
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John B Kisiel
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Mark V Larson
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Seth R Sweetser
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Robert R Sedlack
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Stephen N Sinicrope
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ellen Richmond
- Biomedical Statistics & Informatics, Mayo Clinic, Rochester, Minnesota
| | - Asad Umar
- Biomedical Statistics & Informatics, Mayo Clinic, Rochester, Minnesota
| | - Gary Della'Zanna
- Biomedical Statistics & Informatics, Mayo Clinic, Rochester, Minnesota
| | - Joni S Noaeill
- Divisions of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey P Meyers
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Nathan R Foster
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
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24
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Dobashi A, Goda K, Furuhashi H, Matsui H, Hara Y, Kamba S, Kobayashi M, Sumiyama K, Hirooka S, Hamatani S, Rajan E, Ikegami M, Tajiri H. Diagnostic efficacy of dual-focus endoscopy with narrow-band imaging using simplified dyad criteria for superficial esophageal squamous cell carcinoma. J Gastroenterol 2019; 54:501-510. [PMID: 30406847 DOI: 10.1007/s00535-018-1527-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/26/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Our previous studies have shown the diagnostic utility of a newly developed dual-focus endoscope with narrow-band imaging (DF-NBI) and simplified dyad criteria for detection of superficial esophageal squamous cell carcinoma (SESCC). This clinical trial aimed to study the diagnostic efficacy of DF-NBI with dyad criteria for detecting SESCC compared to white light imaging (WLI). METHODS This was a single-arm prospective comparative trial. We enrolled 170 consecutive high-risk patients for esophageal squamous cell carcinoma. Patients were initially examined with WLI by one independent endoscopist and then the other performed DF-NBI blinded to the WLI diagnosis to avoid a carry-over effect. Lesions showing proliferation and/or various shapes of intrapapillary capillary loops (IPCL) under DF-NBI (i.e., dyad criteria) were endoscopically diagnosed as SESCC including high-grade intraepithelial neoplasia. The primary endpoint was sensitivity of WLI and DF-NBI for detecting SESCC. The secondary endpoints were the diagnostic performance (i.e., specificity and accuracy) and inter/intra-observer concordance of DF-NBI with dyad criteria. RESULTS A total 77 SESCCs were detected. The sensitivity of DF-NBI for SESCC was significantly higher than that of WLI (91% vs. 51%, P < 0.001). The specificity and accuracy of WLI and DF-NBI using dyad criteria were 100% vs. 84%, and 86% vs. 86%, respectively. Various shapes and proliferation of IPCL showed the highest value in inter-observer and intra-observer agreements (κ = 0.77 and 0.82, respectively). CONCLUSION DF-NBI combined with dyad criteria may be a promising technique with a high sensitivity for diagnosis of SESCC and high inter/intra-observer agreement.
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Affiliation(s)
- Akira Dobashi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan. .,Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Kenichi Goda
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan.,Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
| | - Hiroto Furuhashi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroaki Matsui
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuko Hara
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Kamba
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Masakuni Kobayashi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinichi Hirooka
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shigeharu Hamatani
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Elizabeth Rajan
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Masahiro Ikegami
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hisao Tajiri
- Department of Innovative Interventional Endoscopy Research, The Jikei University School of Medicine, Tokyo, Japan
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25
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Al-Bawardy B, Kamboj AK, Desai S, Gorospe E, Bruining DH, Gostout CJ, Hansel SL, Larson MV, Murray JA, Nehra V, Leggett CL, Szarka LA, Watson RE, Rajan E. Patient-oriented education and visual-aid intervention are inadequate to identify patients with potential capsule retention: a prospective randomized study. Scand J Gastroenterol 2019; 54:662-665. [PMID: 31034255 DOI: 10.1080/00365521.2019.1608465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background/aims: The key procedure-related risk with video capsule endoscopy (VCE) is capsule retention, which should be suspected in patients who have not reported capsule passage. The study aims were to determine the frequency of capsule passage visualization and the difference in self-reporting of capsule passage between patients who receive patient-oriented education (POE) and patients who receive POE and a visual aid intervention in the form of a wrist band (WB). Methods: This was a prospective randomized study that enrolled patients undergoing VCE. Patients were randomly assigned to a POE group versus a POE and WB group. POE consisted of verbal education and an information booklet. Both groups received instructions to notify the study team regarding capsule passage. Results: Sixty patients (mean age 57 ± 18 years; 61% female) were included. A total of 57 patients were included in the analysis (3 lost to follow-up; 28 in POE group; 29 in WB group). Capsule passage status was reported by 68% without significant difference between POE and WB groups (72% vs. 64%; p = .51). Capsule passage status was obtained from all 57 patients with the addition of a proactive follow-up. Only 56% (n = 32) reported visualizing capsule passage. Of the remaining patients who did not visualize capsule passage, 60% (n = 15) reported on this without significant difference between the POE and WB groups (p = .23). Conclusions: Lack of visualization of capsule passage is a poor indicator of retention. Self-reporting of VCE passage status is suboptimal and the addition of a visual aid did not improve this parameter.
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Affiliation(s)
- Badr Al-Bawardy
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Amrit K Kamboj
- b Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - Shiv Desai
- c Division of Gastroenterology and Hepatology , University of Pittsburgh Medical Center , Pittsburgh , PA , USA
| | - Emmanuel Gorospe
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - David H Bruining
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | | | - Stephanie L Hansel
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Mark V Larson
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Joseph A Murray
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Vandana Nehra
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Cadman L Leggett
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Lawrence A Szarka
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
| | - Robert E Watson
- d Department of Radiology , Mayo Clinic , Rochester , MN , USA
| | - Elizabeth Rajan
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Rochester , MN , USA
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26
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Levy MJ, Gleeson FC, Topazian MD, Fujii-Lau LL, Enders FT, Larson JJ, Mara K, Abu Dayyeh BK, Alberts SR, Hallemeier CL, Iyer PG, Kendrick ML, Mauck WD, Pearson RK, Petersen BT, Rajan E, Takahashi N, Vege SS, Wang KK, Chari ST. Combined Celiac Ganglia and Plexus Neurolysis Shortens Survival, Without Benefit, vs Plexus Neurolysis Alone. Clin Gastroenterol Hepatol 2019; 17:728-738.e9. [PMID: 30217513 DOI: 10.1016/j.cgh.2018.08.040] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic cancer produces debilitating pain that opioids often ineffectively manage. The suboptimal efficacy of celiac plexus neurolysis (CPN) might result from brief contact of the injectate with celiac ganglia. We compared the effects of endoscopic ultrasound-guided celiac ganglia neurolysis (CGN) vs the effects of CPN on pain, quality of life (QOL), and survival. METHODS We performed a randomized, double-blind trial of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain; 60 patients (age 66.4±11.6 years; male 66%) received CPN and 50 patients (age 66.8±10.0 years; male 56%) received CGN. Primary outcomes included pain control and QOL at week 12 and survival (overall median and 12 months). Secondary outcomes included morphine response, performance status, secondary neurolytic effects, and adverse events. RESULTS Rates of pain response at 12 weeks were 46.2% for CGN and 40.4% for CPN (P = .84). There was no significant difference in improvement of QOL between the techniques. The median survival time was significantly shorter for patients receiving CGN (5.59 months) compared to (10.46 months) (hazard ratio for CGN, 1.49; 95% CI, 1.02-2.19; P = .042), particularly for patients with non-metastatic disease (hazard ratio for CGN, 2.95; 95% CI, 1.61-5.45; P < .001). Rates of survival at 12 months were 42% for patients who underwent CPN vs 26% for patients who underwent CGN. The number of adverse events did not differ between techniques. CONCLUSION In a prospective study of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain, we found CGN to reduce median survival time without improving pain, QOL, or adverse events, compared to CPN. The role of CGN must be therefore be reassessed. Clinicaltrials.gov no: NCT01615653.
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Affiliation(s)
- Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Felicity T Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Joseph J Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Kristin Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - William D Mauck
- Department of Pain Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Santhi S Vege
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
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27
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Dobashi A, Wu SW, Deters JL, Miller CA, Knipschield MA, Cameron GP, Lu L, Rajan E, Gostout CJ. Endoscopic magnet placement into subadventitial tunnels for augmenting the lower esophageal sphincter using submucosal endoscopy: ex vivo and in vivo study in a porcine model (with video). Gastrointest Endosc 2019; 89:422-428. [PMID: 30261170 DOI: 10.1016/j.gie.2018.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/17/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endolumenal therapies serve as a treatment option for GERD. This study aimed to determine if magnets could be placed endoscopically using the adventitial layer to create a subadventitial space near the esophagogastric junction to augment the lower esophageal sphincter using submucosal endoscopy. METHODS This study consisted of 2 phases, ex vivo and in vivo, with domestic pig esophagus. A long submucosal tunnel was made at the mid to lower esophagus. The muscularis propria was incised by a needle-knife within the submucosal tunnel. A subadventitial tunnel was made by biliary balloon catheter blunt dissection, and a magnet was deployed in the subadventitial space. The same maneuver was done within the opposing esophageal wall, with magnet placement in the opposing subadventitial space. RESULTS Submucosal tunnels and subadventitial tunnels were successful without perforation ex vivo in all attempts and in 9 of 10 cases, respectively. Magnets were deployed in the subadventitial space in 7 cases. Magnets connected and separated with atraumatic endoscope passage into the stomach and reconnected when the endoscope was withdrawn under fluoroscopy in 5 of 7 cases (71.4%). In vivo submucosal tunnels and subadventitial tunnels were successful in all 5 cases, and magnet augmentation was functionally active in 4 cases (80%). CONCLUSION Subadventitial tunnels were feasible and could represent a new working space for endoscopic treatment. Endoscopic placement of magnets within the subadventitial space may be an attractive alternative endolumenal therapy for GERD.
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Affiliation(s)
- Akira Dobashi
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shu-Wei Wu
- Department of Physiology and Biomedical Engineering and Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jodie L Deters
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles A Miller
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary A Knipschield
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Graham P Cameron
- Electronics Development Unit, Division of Engineering and Technology Services, Mayo Clinic, Rochester, Minnesota, USA
| | - Lichun Lu
- Department of Physiology and Biomedical Engineering and Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher J Gostout
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Malikowski T, Lehrke HD, Henry MR, Gleeson FC, Topazian MD, Harmsen WS, Takahashi N, Inoue D, Gara N, Abu Dayyeh BK, Chari ST, Iyer PG, Rajan E, Wang KK, Levy MJ. Accuracy of Endoscopic Ultrasound Imaging in Distinguishing Celiac Ganglia From Celiac Lymph Nodes. Clin Gastroenterol Hepatol 2019; 17:148-155.e3. [PMID: 29857152 DOI: 10.1016/j.cgh.2018.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 05/01/2018] [Accepted: 05/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic ultrasound (EUS) allows visualization of celiac lymph nodes (CLNs) and celiac ganglia (CG). Reliably distinguishing these structures is important for tumor staging and CG ablative therapies. We aimed to evaluate the accuracy of EUS in distinguishing CLNs from CG using a strict cytopathology reference standard. We also determined the rate of detection of CLN and CG by conventional cross-sectional imaging. METHODS From EUS and cytopathology databases, we identified all patients who underwent EUS-FNA of a presumed CLN or CG from October 1, 2004, through March 1, 2017, and compared the findings with those from cytology (reference standard). Indeterminate cytology results were re-reviewed. EUS imaging (ie, index test) results were compared with those from the reference standard. An expert radiologist re-reviewed computed tomography and magnetic resonance images from 100 lesions, from 94 randomly selected patients with a reference standard, to determine the rates of CLN and CG detection. RESULTS A total of 504 patients (mean age, 63.4 ± 13.2 years; 292 men) underwent a median of 7 EUS-FNA passes (range, 1-13) for a total of 566 lesions perceived to be either a CLN or CG; the cytology reference standard was available for 521 lesions (92.1%). When we excluded indeterminate cytology results, the EUS accurately identified 281/286 CLNs (98.3%) and 166/186 CGs (89.2%), for an overall accuracy of 447/472 (94.7%). EUS-FNA distinguished CG from CLNs with a 93.3% sensitivity, 93.7% specificity, a positive predictive value of 96.2%, and a negative predictive value of 89.2%. Of 100 lesions in 94 patients randomly selected for a second expert radiology review, computed tomography and magnetic resonance imaging detected 59/67 CLNs (88.1%) and 13/33 CG (39.4%). CONCLUSION EUS accurately distinguishes CLNs from CG. EUS might therefore be used to increase the accuracy of tumor staging, to select tumor stage-appropriate therapy, and to guide CG-ablative therapies.
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Affiliation(s)
| | - Heidi D Lehrke
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Michael R Henry
- Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Dai Inoue
- Department of Radiology, Kanazawa University, Kanazawa, Japan
| | - Naveen Gara
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
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Al-Bawardy B, Schettle SD, Gorospe E, Kee Song LMW, Pereira NL, Alexander JA, Bruining DH, Coelho-Prabhu N, Fidler JL, Mauermann WJ, Barbara DW, Dierkhising R, Rajan E. Small bowel bleeding in patients with left ventricular assist device: outcomes of conservative therapy versus balloon-assisted enteroscopy. Ann Gastroenterol 2018; 31:692-697. [PMID: 30386119 PMCID: PMC6191869 DOI: 10.20524/aog.2018.0316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background Small bowel bleeding (SBB) accounts for 30% of gastrointestinal bleeding (GIB) episodes in patients with a left ventricular assist device (LVAD). The aim of this study was to determine the outcomes of conservative therapy (CT) compared to balloon-assisted enteroscopy (BAE) in the management of SBB in LVAD patients. Methods A retrospective review was performed of a prospectively maintained LVAD database from January 2003 to July 2015. LVAD patients with SBB were classified into a BAE group or a CT group according to whether they did or did not undergo BAE. Results Forty-two patients (22 BAE, 20 CT) with mean age 66±9.3 years (79% male) were included. The yield of BAE was 64% without reported complications. Overt re-bleeding occurred in 40% of the BAE group compared to 22% of the CT group. The BAE group had a higher mean number of GIB hospitalizations per month compared to the CT group (0.07 vs. 0.03; incidence rate ratio [IRR] 2.72, 95% CI 1.06-6.98; P=0.04). There was no significant difference between the BAE and the CT groups in the number of packed red blood cell (pRBC) transfusions per month (0.42 vs. 0.18; IRR 2.31, 95% CI 0.88-6.04; P=0.09) or all-cause mortality (61% in the CT group and 42% in the BAE group; P=0.90). Conclusion BAE is safe in LVAD patients and has a moderate therapeutic yield. In our cohort of patients, BAE did not appear to improve re-bleeding rate, GIB-related hospitalizations, pRBC transfusions or mortality compared to CT. However, future prospective trials with larger sample sizes are needed to confirm these findings.
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Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Sarah D Schettle
- Department of Cardiology (Sarah D. Schettle, Naveen L. Pereira), Mayo Clinic, Rochester, Rochester, MN, USA
| | - Emmanuel Gorospe
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Louis M Wong Kee Song
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Naveen L Pereira
- Department of Cardiology (Sarah D. Schettle, Naveen L. Pereira), Mayo Clinic, Rochester, Rochester, MN, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - David H Bruining
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Nayantara Coelho-Prabhu
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
| | - Jeff L Fidler
- Department of Radiology (Jeff L. Fidler), Mayo Clinic, Rochester, Rochester, MN, USA
| | - William J Mauermann
- Department of Anesthesiology (William J. Mauermann, David W. Barbara), Mayo Clinic, Rochester, Rochester, MN, USA
| | - David W Barbara
- Department of Anesthesiology (William J. Mauermann, David W. Barbara), Mayo Clinic, Rochester, Rochester, MN, USA
| | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics (Ross Dierkhising), Mayo Clinic, Rochester, Rochester, MN, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology (Badr Al-Bawardy, Emmanuel Gorospe, Louis M. Wong Kee Song, Jeffrey A. Alexander, David H. Bruining, Nayantara Coelho-Prabhu, Elizabeth Rajan)
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Dobashi A, Storm AC, Wong Kee Song LM, Gostout CJ, Deters JL, Miller CA, Knipschield MA, Rajan E. Efficacy and safety of an internal magnet traction device for endoscopic submucosal dissection: ex vivo study in a porcine model (with video). Surg Endosc 2018; 33:663-668. [PMID: 30353242 DOI: 10.1007/s00464-018-6486-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/11/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Appropriate traction allows for safer and easier endoscopic submucosal dissection (ESD). The aim of this study was to evaluate the efficacy and safety of an internal magnet traction device (MTD) for ESD in an ex vivo porcine model. METHODS The MTD consisted of a small neodymium magnet and a suture attached to a through-the-scope clip. A circumferential mucosal incision was completed around a 30-mm diameter template that served as the target lesion. The first MTD was deployed at the proximal edge of the lesion. A second MTD was deployed on the wall opposite the lesion. With both magnets connected, this created traction or lifting of the target lesion towards the opposing wall during submucosal dissection. Primary endpoint was comparison of submucosal dissection times between conventional ESD (C-ESD) and MTD-assisted ESD (MTD-ESD). RESULTS Twenty lesions along the anterior wall, posterior wall and greater curvature were resected using either C-ESD or MTD-ESD. The submucosal dissection time in MTD-ESD was significantly shorter than C-ESD (median: 6.4 [interquartile range {IQR} 4.6-8.7] min vs. 14.4 min [IQR 11.8-18.0], p < 0.05). There was a significant difference between MTD-ESD and C-ESD in total procedure times for lesions on the posterior gastric wall and greater curvature (median: 23.0 min [IQR 21.1-24.5] vs. 29.2 min [IQR 24.8-33.2], p < 0.05) with no difference for lesions on the anterior gastric wall (median: 18.8 min [IQR 15.5-20.5] vs. 17.1 min [IQR 13.1-20.0], p = 0.5). The number of muscularis propria injuries per lesion was significantly lower in MTD-ESD than C-ESD (median: 0 [IQR 0-0] vs. 1 [IQR 0-2], p < 0.05). CONCLUSIONS MTD for ESD is effective and safe when compared to C-ESD. This approach significantly reduced submucosal dissection times with less injury to the muscularis propria. Furthermore, MTD-ESD was particularly beneficial for more challenging gastric lesions located on the posterior wall and greater curvature.
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Affiliation(s)
- Akira Dobashi
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrew C Storm
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Louis M Wong Kee Song
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher J Gostout
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jodie L Deters
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Charles A Miller
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mary A Knipschield
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth Rajan
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Al-Bawardy B, Piovezani Ramos G, Lennon RJ, Gorospe E, Wong Kee Song LM, Bruining DH, Alexander JA, Coelho-Prabhu N, Fidler JL, Rajan E. Outcomes of repeat balloon assisted enteroscopy in small-bowel bleeding. Endosc Int Open 2018; 6:E694-E699. [PMID: 29868634 PMCID: PMC5979197 DOI: 10.1055/a-0599-6085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 02/20/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/AIMS The rate of recurrent small-bowel bleeding (SBB) remains high despite the advent of balloon assisted enteroscopy (BAE). The study aims were to determine: (1) the diagnostic and therapeutic yields, and adverse event rate of repeat BAE in SBB, and (2) the predictors of a positive repeat BAE. METHODS A retrospective review of a BAE database was conducted. Patients who had > 1 BAE for SBB were included. Primary outcomes were diagnostic yield, therapeutic yield, and adverse events of repeat BAE. Secondary outcomes were predictors of a positive repeat BAE. RESULTS A total of 175 patients (55 % men; mean age 64.1 ± 16.3 years) were included. The diagnostic and therapeutic yields of repeat BAE were 55 % and 42 %, respectively. Repeat BAE adverse events occurred in 5 % with self-limited abdominal pain being most common. Patients with a positive repeat BAE were significantly older than the negative group (68.6 ± 13.9 vs. 60.9 ± 17.1; P = 0.001) and were more likely to have cardiac comorbidities (OR 2.4, 95 %CI: 1.3 - 4.6; P = 0.01), chronic kidney disease (OR 2.3, 95 %CI: 1.1 - 4.9; P = 0.04), chronic obstructive pulmonary disease (OR 3.3, 95 %CI: 1.3 - 8.1; P = 0.01), positive initial BAE (OR 3.6, 95 %CI: 1.9 - 6.8; P < 0.001), and antegrade procedure (OR 3.3, 95 %CI: 1.7 - 6.1; P < 0.001). On multivariate analysis, a positive initial BAE and antegrade route were the only significant predictive factors. CONCLUSIONS Performing a repeat BAE for SBB appears safe and provided modest yields. A positive initial BAE and antegrade route were predictive of a positive repeat BAE.
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Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Ryan J. Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Emmanuel Gorospe
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - David H. Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Jeff L. Fidler
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA,Corresponding author Elizabeth Rajan, MD Division of Gastroenterology & HepatologyMayo Clinic200 First Street, S.W.RochesterMN 55905USA+1-507-284-0538
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Abstract
Recent advances in minimally invasive endoscopic approaches have pushed the boundaries of well-established resection techniques for therapeutic and diagnostic applications. Endoscopic full thickness resection techniques are a key development in the management of challenging epithelial and subepithelial lesions that are not amenable to conventional endoscopic resection methods and previously required a surgical approach. Endoscopic full thickness biopsy represents a paradigm shift in tissue acquisition and will enhance our understanding of the pathophysiology, and guide therapy, of gastrointestinal neuromuscular diseases, as well as other inflammatory and neoplastic conditions. This review highlights current tools and techniques available for endoscopic full thickness resection and biopsy, as well as outcomes from such interventions.
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Affiliation(s)
- Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Larson A, Gleeson F, Rajan E. A 25-Year-Old Woman With a Deceptive Pancreas Cyst: All Is Not as It Appears! Gastroenterology 2018; 154:e14-e15. [PMID: 28736256 DOI: 10.1053/j.gastro.2017.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/14/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Alexander Larson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ferga Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Dobashi A, Rajan E, Knipschield MA, Gostout CJ. Endoscopic full-thickness resection using suture loop needle T-tag tissue anchors in the porcine stomach (with video). Gastrointest Endosc 2018; 87:590-596. [PMID: 28734991 DOI: 10.1016/j.gie.2017.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic full-thickness resection (EFTR) is still challenging, and a reliable technique is desirable. The aim of this study was to evaluate the feasibility of controlled EFTR using a pseudopolyp made from suture loop needle T-tag (SLNT) tissue anchors in ex vivo porcine stomachs. METHODS Five pig stomachs were used. Two concentric circumferential border mucosal incisions were made to facilitate isolating a target lesion for full-thickness excision and pseudopolyp formation. SLNT tissue anchors were placed with a fishing line around the edges of the larger outer incision by endoscopic suturing. A suture pulley was created in the center of the targeted area and brought outside for traction. A large inverted pseudopolyp of the targeted lesion was made, visualizing apposing serosa with traction on the suture pulley while simultaneously cinching the encircling fishing line. EFTR was then performed on the isolated targeted tissue with the use of a needle-knife. RESULTS Pseudopolyps were successful in all attempts. In the first attempt the encircling fishing line was cut, releasing the pseudopolyp during EFTR, with obvious leak. The remaining 4 EFTRs were performed with intact serosal apposing pseudopolyps and no air leaks. The median number of SLNT tissue anchors placed for a pseudopolyp was 5 (interquartile range, 4-5). The median size of full-thickness lesions was 37 mm (interquartile range, 29-49) and the median maximum pressure for the leak testing 9 mm Hg (interquartile range, 4-14) in the successful 4 attempts. CONCLUSION This proof of principle study suggests that EFTR with SLNT-fashioned pseudopolyps is feasible.
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Affiliation(s)
- Akira Dobashi
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary A Knipschield
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher J Gostout
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Al-Bawardy B, Rajan E, Wong Kee Song LM. Response. Gastrointest Endosc 2017; 86:750-751. [PMID: 28917355 DOI: 10.1016/j.gie.2017.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 06/12/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Rustagi T, Gleeson FC, Chari ST, Abu Dayyeh BK, Farnell MB, Iyer PG, Kendrick ML, Pearson RK, Petersen BT, Rajan E, Topazian MD, Truty MJ, Vege SS, Wang KK, Levy MJ. Remote malignant intravascular thrombi: EUS-guided FNA diagnosis and impact on cancer staging. Gastrointest Endosc 2017; 86:150-155. [PMID: 27773725 DOI: 10.1016/j.gie.2016.10.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/09/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Malignant vascular invasion usually results from gross direct infiltration from a primary tumor and impacts cancer staging, prognosis, and therapy. However, patients may also develop a remote malignant thrombi (RMT), defined as a malignant intravascular thrombus located remote and noncontiguous to the primary tumor. Our aim was to compare EUS, CT, and magnetic resonance imaging (MRI) findings of RMT and to explore the potential impact on cancer staging. METHODS Patients with RMT were identified from a prospectively maintained EUS database. Retrospective chart review was performed to obtain EUS, CT/MRI, clinical, and outcome data. RESULTS A median of 3 FNAs (range, 1-8) was obtained from RMT in 17 patients (60 ± 14.1 years, 56% men) between April 2003 and August 2016, with the finding of malignant cytology in 12 patients (70.6%; 10 positive, 2 suspicious). CT/MRI detected the RMT in 5 patients (29.4%), 4 of whom had positive or suspicious EUS-FNA cytology. Among the 8 newly diagnosed pancreatic adenocarcinoma (PaC) patients, CT did not detect the RMT in 5 (63%), of whom 3 patients had positive or suspicious intravascular EUS-FNA cytology. For newly diagnosed PaC patients (n = 8), the EUS-FNA diagnosis of a biopsy specimen-proven RMT upstaged 3 patients (37.5%) and converted 2 patients (25%) from CT resectable to unresectable disease. No adverse events were reported. The mean follow-up was 18.9 ± 27.7 months. CONCLUSIONS Our study demonstrates the ability and potential safety of intravascular FNA to detect radiographically occult RMT, which substantially impacts cancer staging and resectability.
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Affiliation(s)
- Tarun Rustagi
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Randall K Pearson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
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Al-Bawardy B, Rajan E, Wong Kee Song LM. Over-the-scope clip-assisted endoscopic full-thickness resection of epithelial and subepithelial GI lesions. Gastrointest Endosc 2017; 85:1087-1092. [PMID: 27569858 DOI: 10.1016/j.gie.2016.08.019] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/17/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic full-thickness resection (EFTR) allows for definitive diagnosis and treatment of select subepithelial and epithelial lesions unsuitable to conventional resection techniques. Our aim was to evaluate the efficacy and safety of over-the-scope (OTS) clip-assisted EFTR for these lesions. METHODS Patients who underwent OTS clip-assisted EFTR between June 2014 and October 2015 were analyzed. The procedure involved (1) thermal marking of the periphery of the lesion; (2) lesion suction into the cap of either an OTSC (Ovesco Endoscopy AG, Tübingen, Germany) or Padlock clip (Aponos Medical Corp, Kingston, NH, USA) with or without triprong anchor retraction of the lesion; (3) clip deployment; and (4) en bloc resection of the lesion above the clip using an electrosurgical snare and/or knife. Data were abstracted for demographics, lesion features, histopathologic diagnoses, R0 resection (negative margins) status, and adverse events. RESULTS Nine patients (7 men) with a mean age of 63 ± 9.6 years were identified. The endoscopic findings included subepithelial lesions in the duodenum (n = 4), rectosigmoid colon (n = 2), stomach (n = 1), and postappendectomy appendiceal orifice polyps (n = 2). The mean lesion size was 8 ± 3 mm and the mean procedure time 53 ± 21 minutes. R0 resection was confirmed in all cases. The histopathologic diagnoses included neuroendocrine tumors (n = 6), sessile serrated adenomas (n = 2), and pancreatic heterotopia (n = 1). No adverse events were noted. CONCLUSIONS OTS clip-assisted EFTR is an effective and safe technique for the removal of select subepithelial and epithelial lesions that are not amenable to conventional resection techniques.
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Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Rustagi T, Gleeson FC, Chari ST, Abu Dayyeh BK, Farnell MB, Iyer PG, Kendrick ML, Pearson RK, Petersen BT, Rajan E, Topazian MD, Truty MJ, Vege SS, Wang KK, Levy MJ. Endoscopic Ultrasound Fine-Needle Aspiration Diagnosis of Synchronous Primary Pancreatic Adenocarcinoma and Effects on Staging and Resectability. Clin Gastroenterol Hepatol 2017; 15:299-302.e4. [PMID: 27539084 DOI: 10.1016/j.cgh.2016.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 08/04/2016] [Accepted: 08/08/2016] [Indexed: 12/13/2022]
Abstract
Synchronous primary pancreatic adenocarcinoma, defined as the simultaneous presence of 2 or more newly identified and anatomically separate primary adenocarcinomas within the pancreas, is reported rarely. We compared endoscopic ultrasound (EUS) and computed tomography (CT) and magnetic resonance imaging (MRI) findings from patients with synchronous primary pancreatic adenocarcinoma and their effects on cancer staging and treatment. We performed a retrospective analysis of the EUS database at the Mayo Clinic, from September 2008 through May 2016, to collect EUS, CT, MRI, and clinical data from patients with synchronous primary pancreatic adenocarcinoma. EUS and separate fine-needle aspiration of both tumors detected synchronous primary pancreatic adenocarcinoma in 11 patients (70.9 ± 10.4 y; 64% men). Of the 22 cancers, CT (n = 9) and MRI (n = 2) detected 9 (41%) cancers; in only 2 patients did CT detect both cancers. EUS increased cancer stage for 7 of the 11 (64%) patients and changed the status from resectable to unresectable for 3 of the 9 (33%) patients, compared with CT or MRI. EUS findings altered the likely extent of surgical resection for 3 patients. Synchronous primary pancreatic adenocarcinoma is reported rarely and may be undetected by CT or MRI; this could account for the false presumption of early tumor recurrence, rather than actual residual second tumor, leading to incomplete resection.
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Affiliation(s)
- Tarun Rustagi
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Prasad G Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Santhi S Vege
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
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Law R, Varayil JE, WongKeeSong LM, Fidler J, Fletcher JG, Barlow J, Alexander J, Rajan E, Hansel S, Becker B, Larson JJ, Enders FT, Bruining DH, Coelho-Prabhu N. Assessment of multi-modality evaluations of obscure gastrointestinal bleeding. World J Gastroenterol 2017; 23:614-621. [PMID: 28216967 PMCID: PMC5292334 DOI: 10.3748/wjg.v23.i4.614] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 09/16/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the frequency of bleeding source detection in patients with obscure gastrointestinal bleeding (OGIB) who underwent double balloon enteroscopy (DBE) after pre-procedure imaging [multiphase computed tomography enterography (MPCTE), video capsule endoscopy (VCE), or both] and assess the impact of imaging on DBE diagnostic yield.
METHODS Retrospective cohort study using a prospectively maintained database of all adult patients presenting with OGIB who underwent DBE from September 1st, 2002 to June 30th, 2013 at a single tertiary center.
RESULTS Four hundred and ninety five patients (52% females; median age 68 years) underwent DBE for OGIB. AVCE and/or MPCTE performed within 1 year prior to DBE (in 441 patients) increased the diagnostic yield of DBE (67.1% with preceding imaging vs 59.5% without). Using DBE as the gold standard, VCE and MPCTE had a diagnostic yield of 72.7% and 32.5% respectively. There were no increased odds of finding a bleeding site at DBE compared to VCE (OR = 1.3, P = 0.150). There were increased odds of finding a bleeding site at DBE compared to MPCTE (OR = 5.9, P < 0.001). In inpatients with overt OGIB, diagnostic yield of DBE was not affected by preceding imaging.
CONCLUSION DBE is a safe and well-tolerated procedure for the diagnosis and treatment of OGIB, with a diagnostic yield that may be increased after obtaining a preceding VCE or MPCTE. However, inpatients with active ongoing bleeding may benefit from proceeding directly to antegrade DBE.
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Abu Dayyeh BK, Acosta A, Camilleri M, Mundi MS, Rajan E, Topazian MD, Gostout CJ. Endoscopic Sleeve Gastroplasty Alters Gastric Physiology and Induces Loss of Body Weight in Obese Individuals. Clin Gastroenterol Hepatol 2017; 15:37-43.e1. [PMID: 26748219 DOI: 10.1016/j.cgh.2015.12.030] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/11/2015] [Accepted: 12/11/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although bariatric surgery is the most effective therapy for obesity, only a small proportion of candidates undergo this surgery. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that reduces the size of the gastric reservoir. We investigated its durability and effects on body weight and gastrointestinal function in a prospective study of obese individuals. METHODS Twenty-five obese individuals (21 female; mean body mass index, 35.5 ± 2.6 kg/m2; mean age, 47.6 ± 10 years) underwent ESG with endoluminal creation of a sleeve along the gastric lesser curve from September 2012 through March 2015 at the Mayo Clinic in Rochester, Minnesota. Subjects were followed for a median period of 9 months. We measured changes in body weight and recorded adverse events; patients were assessed by endoscopy after 3 months. Four participants underwent pre-ESG and post-ESG analyses to measure solid and liquid gastric emptying, satiation (meal tolerance), and fasting and postprandial levels of insulin, glucose, and gut hormones. RESULTS Subjects had lost 53% ± 17%, 56% ± 23%, 54% ± 40%, and 45% ± 41% of excess body weight at 6, 9, 12, and 20 months, respectively, after the procedure (P < .01). Endoscopy at 3 months showed intact gastroplasty in all subjects. After ESG, physiological analyses of 4 participants showed a decrease by 59% in caloric consumption to reach maximum fullness (P = .003), slowing of gastric emptying of solids (P = .03), and a trend toward increased insulin sensitivity (P = .06). Three patients had serious adverse events (a perigastric inflammatory collection, a pulmonary embolism, and a small pneumothorax) but made full recoveries with no need for surgical interventions. No further serious adverse events occurred after the technique was adjusted. CONCLUSIONS ESG delays gastric emptying, induces early satiation, and significantly reduces body weight. ESG could be an alternative to bariatric surgery for selected patients with obesity. ClincialTrials.gov number: NCT 01682733.
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Affiliation(s)
- Barham K Abu Dayyeh
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Andres Acosta
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Manpreet S Mundi
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Rajan
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark D Topazian
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher J Gostout
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Hampel P, Ramos GP, Binder M, Neto MB, Sunjaya D, Al Bawardy B, Rajan E. Endoscopic management of gastrointestinal bleeding in cancer patients with severe thrombocytopenia. Eur J Surg Oncol 2016. [DOI: 10.1016/j.ejso.2016.07.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Rajan E, Gostout CJ, Wong Kee Song LM, Szarka LA, Kashyap PC, Smyrk TC, Bingener J, Deters JL, Knipschield MA, Bernard CE, Farrugia G. Innovative gastric endoscopic muscle biopsy to identify all cell types, including myenteric neurons and interstitial cells of Cajal in patients with idiopathic gastroparesis: a feasibility study (with video). Gastrointest Endosc 2016; 84:512-7. [PMID: 27129395 PMCID: PMC4991873 DOI: 10.1016/j.gie.2016.04.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 04/17/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The pathophysiology of some GI neuromuscular diseases remains largely unknown. This is in part due to the inability to obtain ample deep gastric wall biopsies that include the intermuscular layer of the muscularis propria (MP) to evaluate the enteric nervous system, interstitial cells of Cajal (ICCs), and related cells. We report on a novel technique for gastric endoscopic muscle biopsy (gEMB). METHODS Patients with idiopathic gastroparesis were prospectively enrolled in a feasibility study by using a novel "no hole" gEMB. Main outcome measures were technical success, adverse events, and histologic confirmation of the intermuscular layer, including myenteric neurons and ICC. The gEMB was a double resection clip-assist technique. A site was identified on the anterior wall of the gastric body as recommended by the International Working Group on histologic techniques. EMR was performed to unroof and expose the underlying MP. The exposed MP was then retracted into the cap of an over-the-scope clip. The clip was deployed, and the pseudopolyp of MP created was resected. This resulted in a no-hole gEMB. RESULTS Three patients with idiopathic gastroparesis underwent gEMB. Patients had severe delayed gastric emptying with a mean (± standard deviation [SD]) of 49 ± 16.8% of retained gastric contents at 4 hours. They had no history of gastric or small-bowel surgery and did not use steroids or other immunosuppressive drugs. The gEMB procedure was successfully performed, with no procedural adverse events. Postprocedural abdominal pain was controlled with nonsteroidal anti-inflammatory agents and opioid analgesics. Mean length of resected MP was 10.3 ± 1.5 mm. Mean procedure time was 25.7 ± 6 minutes. Hematoxylin and eosin (H&E) staining of tissue samples confirmed the presence of both inner circular and outer longitudinal muscle, as well as the intermuscular layer. H&E staining showed reduced myenteric ganglia in 1 patient. In 2 patients, specialized immunohistochemistry was performed, which showed a marked decrease in myenteric neurons as delineated by an antibody to protein gene product 9.5 and a severe decrease in ICC levels across the muscle layers. At 1 month follow-up, upper endoscopy showed a well-healed scar in 2 patients and minimal ulceration with a retained clip in 1 patient. CT of the abdomen confirmed the integrity of the gastric wall in all patients. Because of lack of an immune infiltrate in the resected samples, patients were not considered suitable for immunosuppressive or steroid therapy. CONCLUSIONS gEMB is feasible and easy to perform, with acquisition of tissue close to surgical samples to identify myenteric ganglia, ICCs, and multiple cell types. The ability to perform gEMB represents a paradigm shift in endoscopic tissue diagnosis of gastric neuromuscular pathologies.
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Affiliation(s)
| | | | | | - LA Szarka
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - PC Kashyap
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - TC Smyrk
- Division of Anatomic Pathology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - J Bingener
- Department of Surgery, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | | | | | - CE Bernard
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
| | - G Farrugia
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905
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Al-Bawardy B, Gorospe EC, Alexander JA, Bruining DH, Coelho-Prabhu N, Rajan E, Wong Kee Song LM. Outcomes of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy tube placement. Endoscopy 2016; 48:552-6. [PMID: 26964079 DOI: 10.1055/s-0042-101853] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND STUDY AIMS In a large series, conventional direct percutaneous endoscopic jejunostomy (DPEJ) tube placement with push endoscopes failed in approximately one-third of patients. In a pilot study, double-balloon enteroscopy (DBE)-assisted DPEJ tube placement was successful in all patients in whom attempted conventional DPEJ had failed. The study aim was to assess the technical success of and adverse events related to DBE-DPEJ tube placement in a large cohort of patients. PATIENTS AND METHODS The medical records of all patients who underwent DBE-DPEJ tube placement between July 2010 and November 2013 were reviewed using a prospectively maintained electronic database. Data were abstracted for patient demographics, indications for DPEJ, gut anatomy, technical success rate, causes of failure, and adverse events. RESULTS The study comprised a total of 94 patients (39 men; mean age 56 years; body mass index [BMI] 23 ± 6.4 kg/m(2)). The most common indication for DPEJ was gastroparesis (n = 29). Altered gut anatomy was present in 36 patients (38 %). DBE-DPEJ tube placement was technically successful in 87 patients (93 %). The mean procedure duration was 33 minutes (range 15 - 88). DBE-DPEJ tube placement failed in seven patients (7 %), primarily because of limited instrument advancement in the setting of presumed surgical adhesions. Post-procedural adverse events occurred in eight patients (9 %), with one serious adverse event, which was a gastric interposition requiring surgical repair. CONCLUSIONS Compared with the published outcomes of DPEJ by conventional endoscopy, DBE-DPEJ tube placement was technically successful in a high proportion of patients (93 %) and with a relatively low rate of significant adverse events.
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Affiliation(s)
- Badr Al-Bawardy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Emmanuel C Gorospe
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey A Alexander
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Gómez V, Takahashi N, Levy MJ, McGee KP, Jones A, Huang Y, Chari ST, Clain JE, Gleeson FC, Pearson RK, Petersen BT, Rajan E, Vege SS, Topazian MD. EUS-guided ethanol lavage does not reliably ablate pancreatic cystic neoplasms (with video). Gastrointest Endosc 2016; 83:914-20. [PMID: 26363331 DOI: 10.1016/j.gie.2015.08.069] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/07/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The true efficacy of EUS-guided ethanol lavage (EEL) of pancreatic cystic neoplasms is unclear. This study aimed to assess long-term outcomes and adverse events of EEL by using a standardized protocol. METHODS Single-center, prospective, pilot study in which participants with suspected mucinous cyst neoplasms or branch duct intraductal papillary mucinous neoplasms ≥1 cm in maximum diameter underwent EEL with 80% ethanol. Follow-up cross-sectional imaging was obtained to assess for changes in cyst volume. RESULTS Twenty-three patients underwent EEL (57% male, mean age 70 years). Mean duration of follow-up was 40 months (range 9-82 months). Mean calculated final concentration of ethanol achieved in treated cysts was 50% (range 0%-79%). Complete resolution of pancreatic cystic neoplasms occurred in 2 participants (9%). When stratified into those participants who achieved ≥80% versus <80% reduction in cyst volume, no statistically significant differences were seen with regard to patient demographics, cyst characteristics, or final concentration of ethanol achieved in the treated cyst. Greater decreases in cyst volume were seen in presumed nonmucinous cysts compared with presumed mucinous cysts (P = .006). Two early adverse events occurred. Five participants died during the study follow-up period (4 from nonpancreatic causes), including 1 participant who was diagnosed with pancreatic adenocarcinoma thought to have arisen from the treated branch duct intraductal papillary mucinous neoplasm 41 months after undergoing EEL. CONCLUSIONS As performed in this study, EEL therapy does not appear to be a promising method for prevention of malignancy in pancreatic cysts. Endoscopic methods that effectively and completely ablate pancreatic cystic neoplasms are needed. ( CLINICAL TRIAL REGISTRATION NUMBER NCT02158039.).
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Affiliation(s)
- Victoria Gómez
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kiaran P McGee
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Jones
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yajue Huang
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan E Clain
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall K Pearson
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mark D Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
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Schettle S, Al Bawardy B, Sherazi S, Cheyne C, Kushwaha S, Rajan E, Pereira N. Danazol for the Treatment of Gastrointestinal Bleeding in Left Ventricular Assist Device (LVAD) Patients: A Multicenter Experience. J Heart Lung Transplant 2016. [DOI: 10.1016/j.healun.2016.01.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Bick BL, Enders FT, Levy MJ, Zhang L, Henry MR, Abu Dayyeh BK, Chari ST, Clain JE, Farnell MB, Gleeson FC, Kendrick ML, Pearson RK, Petersen BT, Rajan E, Vege SS, Topazian M. The string sign for diagnosis of mucinous pancreatic cysts. Endoscopy 2015; 47:626-31. [PMID: 25730281 DOI: 10.1055/s-0034-1391484] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND STUDY AIMS Pancreas cyst fluid analysis does not provide optimal discrimination between mucinous and nonmucinous cysts. The aim of this study was to assess the performance characteristics of the "string sign" - a test performed at the time of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), for the diagnosis of mucinous pancreatic cysts (branch duct intraductal papillary mucinous neoplasms [bIPMN] and mucinous cystic neoplasms). PATIENTS AND METHODS Patients undergoing EUS-FNA of pancreatic cystic lesions at one referral center between 2003 and 2012 were included. The string sign was performed prospectively, and was considered positive if ≥ 1 cm string formed in cyst fluid and lasted for ≥ 1 second. Performance characteristics of the string sign and a sequential cyst fluid test interpretation model were assessed. RESULTS For 98 histologically proven cases, the sensitivity, specificity, positive predictive value, and negative predictive value of the string sign for diagnosis of mucinous cysts were 58 % (95 % confidence interval [CI] 44 % - 70 %), 95 % (83 % - 99 %), 94 % (81 % - 99 %), and 60 % (46 % - 72 %), respectively. When string sign results and carcinoembryonic antigen (CEA) concentration (≥ 200 ng/mL) were combined, diagnostic accuracy improved from 74 % and 83 %, respectively, to 89 % (P ≤ 0.03). Among bIPMN, a positive string sign was associated with gastric and intestinal epithelial subtypes. The sequential cyst fluid test interpretation model (including cytology, mucin stain, CEA, and string sign) yielded an overall sensitivity for mucinous lesions of 96 %, with a specificity of 90 %. CONCLUSIONS The string sign is highly specific for diagnosis of mucinous pancreatic cysts, and improves overall diagnostic accuracy of pancreatic cyst fluid analysis. Sequential cyst fluid test interpretation yields high diagnostic sensitivity and specificity for mucinous cysts.
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Affiliation(s)
- Benjamin L Bick
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Felicity T Enders
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Lizhi Zhang
- Department of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael R Henry
- Department of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Jonathan E Clain
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael B Farnell
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael L Kendrick
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Randall K Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Fujii-Lau LL, Bamlet WR, Eldrige JS, Chari ST, Gleeson FC, Abu Dayyeh BK, Clain JE, Pearson RK, Petersen BT, Rajan E, Topazian MD, Vege SS, Wang KK, Wiersema MJ, Levy MJ. Impact of celiac neurolysis on survival in patients with pancreatic cancer. Gastrointest Endosc 2015; 82:46-56.e2. [PMID: 25800661 PMCID: PMC6017988 DOI: 10.1016/j.gie.2014.12.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 12/01/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic cancer (PC) often produces pain that is difficult to control. Celiac neurolysis (CN) is performed with the goal of improving pain control and quality of life while reducing opioid-related side effects. OBJECTIVE We aimed to evaluate whether CN provides a survival advantage for PC patients. DESIGN Retrospective case-control study. SETTING Single tertiary-care referral center. PATIENTS Review of a prospectively maintained database identified patients with unresectable PC who underwent CN over a 12-year period. Each patient was matched to 2 control patients with unresectable PC. INTERVENTION CN, which included both celiac plexus neurolysis (CPN) and celiac ganglia neurolysis (CGN). MAIN OUTCOME MEASUREMENTS Median survival in Kaplan-Meier curves and hazard ratios. RESULTS A total of 417 patients underwent CN and were compared with 840 controls with PC. Baseline characteristics were similar except the CN group had greater weight loss and pain requiring opioids. A mean of 16.6 ± 5.8 mL of alcohol was administered. For patients who underwent CN, the median survival from the time of presentation was shorter compared with controls (193 vs 246 days; hazard ratio 1.32; 95% confidence interval, 1.13-1.54). There was no difference in survival with unilateral or bilateral injection. However, EUS-guided CN was associated with longer survival compared with non-EUS approaches, and those who received CPN had longer survival compared with CGN. LIMITATIONS Single center, retrospective. CONCLUSION Our study suggests that CN is an independent predictor of shortened survival in PC patients. A prospective study is needed to verify the findings and determine whether shortened survival results from CN or from other features such as performance status and tumor-related characteristics. It is also imperative to verify our finding that EUS-guided CN provides a survival advantage over other approaches and whether CPN prolongs survival compared with CGN.
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Fujii-Lau LL, Abu Dayyeh BK, Bruno MJ, Chang KJ, DeWitt JM, Fockens P, Forcione D, Napoleon B, Palazzo L, Topazian MD, Wiersema MJ, Chak A, Clain JE, Faigel DO, Gleeson FC, Hawes R, Iyer PG, Rajan E, Stevens T, Wallace MB, Wang KK, Levy MJ. EUS-derived criteria for distinguishing benign from malignant metastatic solid hepatic masses. Gastrointest Endosc 2015; 81:1188-96.e1-7. [PMID: 25660980 PMCID: PMC5574178 DOI: 10.1016/j.gie.2014.10.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/28/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Detection of hepatic metastases during EUS is an important component of tumor staging. OBJECTIVE To describe our experience with EUS-guided FNA (EUS-FNA) of solid hepatic masses and derive and validate criteria to help distinguish between benign and malignant hepatic masses. DESIGN Retrospective study, survey. SETTING Single, tertiary-care referral center. PATIENTS Medical records were reviewed for all patients undergoing EUS-FNA of solid hepatic masses over a 12-year period. INTERVENTIONS EUS-FNA of solid hepatic masses. MAIN OUTCOME MEASUREMENTS Masses were deemed benign or malignant according to predetermined criteria. EUS images from 200 patients were used to create derivation and validation cohorts of 100 cases each, matched by cytopathologic diagnosis. Ten expert endosonographers blindly rated 15 initial endosonographic features of each of the 100 images in the derivation cohort. These data were used to derive an EUS scoring system that was then validated by using the validation cohort by the expert endosonographer with the highest diagnostic accuracy. RESULTS A total of 332 patients underwent EUS-FNA of a hepatic mass. Interobserver agreement regarding the initial endosonographic features among the expert endosonographers was fair to moderate, with a mean diagnostic accuracy of 73% (standard deviation 5.6). A scoring system incorporating 7 EUS features was developed to distinguish benign from malignant hepatic masses by using the derivation cohort with an area under the receiver operating curve (AUC) of 0.92; when applied to the validation cohort, performance was similar (AUC 0.86). The combined positive predictive value of both cohorts was 88%. LIMITATIONS Single center, retrospective, only one expert endosonographer deriving and validating the EUS criteria. CONCLUSION An EUS scoring system was developed that helps distinguish benign from malignant hepatic masses. Further study is required to determine the impact of these EUS criteria among endosonographers of all experience.
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Affiliation(s)
- Larissa L. Fujii-Lau
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center, Rotterdam, The Netherlands
| | - Kenneth J. Chang
- Division of Gastroenterology and Hepatology, University of California Irvine, Orange, California
| | - John M. DeWitt
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IndianaDivision of Gastroenterology and Hepatology, Academic Medical Center, University of
| | | | - David Forcione
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Bertrand Napoleon
- Department of Gastroenterology, Private Hospital Jean Mermoz, Lyon, France
| | | | - Mark D. Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jonathan E. Clain
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas O. Faigel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Ferga C. Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Michael B. Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J. Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Levy MJ, Abu Dayyeh BK, Fujii LL, Clayton AC, Reynolds JP, Lopes TL, Rao AS, Clain JE, Gleeson FC, Iyer PG, Kendrick ML, Rajan E, Topazian MD, Wang KK, Wiersema MJ, Chari ST. Detection of peritoneal carcinomatosis by EUS fine-needle aspiration: impact on staging and resectability (with videos). Gastrointest Endosc 2015; 81:1215-24. [PMID: 25660979 DOI: 10.1016/j.gie.2014.10.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 10/23/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Peritoneal carcinomatosis (PC) greatly affects cancer staging and resectability. OBJECTIVE To compare the PC detection rate by using EUS and noninvasive imaging and to determine the impact on staging and resectability. DESIGN Retrospective study. SETTING Single tertiary-care referral center. PATIENTS A prospectively maintained EUS database was reviewed to identify patients who underwent EUS-guided FNA (EUS-FNA) of a peritoneal anomaly. Findings were compared with a strict criterion standard that incorporated cytohistologic, radiologic, and clinical data. INTERVENTION EUS-FNA of a peritoneal anomaly. MAIN OUTCOME MEASUREMENTS Safety and diagnostic yield. RESULTS Of 106 patients, a criterion standard was available in 98 (39 female patients; median age, 65 years). The sensitivity, specificity, and accuracy of EUS-FNA versus CT/magnetic resonance imaging (MRI) was 91% versus 28%, 100% versus 85%, and 94% versus 47%, respectively. In newly diagnosed cancer patients, peritoneal FNA upstaged 17 patients (23.6%). Of 32 patients deemed resectable by pre-EUS CT/MRI, 15 (46.9%) were deemed unresectable based solely on peritoneal FNA. The odds of FNA changing the resectability status remained highly significant after adjustment for cancer type, time between CT/MRI and EUS-FNA, and the quality of CT/MRI. The malignant appearance of the peritoneal anomaly but not the presence of ascites on EUS predicted a positive FNA finding (odds ratio 2.56; 95% confidence interval, 1.23-5.4 and odds ratio 0.83; 95% confidence interval, 0.4-1.8, respectively). There were 3 adverse events among 4 patients. Two of the patients developed abdominal pain and one each hypertensive urgency and pancreatitis. LIMITATIONS Retrospective design, single-center, bias toward EUS as a diagnostic test. CONCLUSION Peritoneal EUS-FNA appears to safely detect radiographically occult PC and improve cancer staging and patient care.
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Affiliation(s)
- Michael J Levy
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Larissa L Fujii
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy C Clayton
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jordan P Reynolds
- Department of Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tercio L Lopes
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Archana S Rao
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan E Clain
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael L Kendrick
- Department of Surgery, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Suresh T Chari
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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